New Skin Biopsy Codes: It’s All About the Technique

For 2019, the American Medical Association (AMA) CPT® Editorial Panel will introduce six new codes for primary skin biopsy—three base codes and three add-on codes codes—all of which will be effective January 1, 2019. These three new codes will replace existing codes 11100 and 11101 (skin biopsy), which will be deleted. These new codes have been established for healthcare providers to report biopsy procedures based on the technique used to obtain tissue sample(s).

The AMA CPT Editorial Panel created the following new codes to differentiate between biopsy modalities, namely tangential, punch, and incisional biopsies:

Skin biopsy codes can be reported to indicate that:

• the intent of the procedure was to obtain tissue for diagnostic histopathologic examination; and

• the procedure was performed independently, or was unrelated and distinct from other procedures/ services provided during the same encounter.

Biopsies performed on a different lesion(s) or site(s) on the same date of service may be reported separately, as they are not considered components of the other procedures performed during the same encounter.

National Correct Coding Initiative (NCCI) edits apply; for information on proper use and application of modifiers, see https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html.

Tissue samples obtained during excisions, destructions, or shave removals are routinely submitted for histopathologic evaluation and should not be reported separately.

Unlike existing biopsy codes (11100 and 11101) which do not classify the biopsy technique used for tissue sampling, these new codes (11102, 11104, and 11106) will define three distinct biopsy techniques to clearly describe the service and depth of the tissue sample obtained.

Reporting Multiple Biopsy Procedures During the Same Encounter

When multiple biopsies are performed during the same encounter, only one primary code and one or more additional add-on code(s) appropriate for the biopsy techniques used are reported.

Note: Only one primary code is reported, regardless if multiple biopsy techniques are used.

The following chart illustrates how to report multiple biopsy procedures performed during the same encounter.

The following examples show how to report multiple different biopsy procedures performed during the same encounter.

• An incisional biopsy (11106) should always be reported as the primary procedure code when used with other biopsy techniques.

• A punch biopsy (11104) should be reported as the primary procedure when a tangential biopsy is performed during the same encounter. The tangential biopsy should be reported with the add-on code (11103).

Add-on code 11105 may be reported in conjunction with codes 11104 and 11106, when additional biopsies of the same or different techniques are performed to sample separate/additional lesions during the same encounter. Add-on code 11107 may only be reported in conjunction with code 11106 for incisional biopsy.

Focus on the Intent of the Procedure and Expectations for Proper Documentation

Due to the complexity of the new skin biopsy codes, there is a need to pay close attention to procedural details and intent. Biopsy codes should only be used when the intent is to obtain a tissue sample for histopathologic examination.

Re-education of healthcare provider(s) on medical record documentation is critical. Coding staff will need to adjust medical record review in order to identify procedural intent and technique(s) used during the procedure, so that the appropriate biopsy code can be selected.

The following examples illustrate how the new codes can be applied starting on January 1, 2019.

Example 1

A 58-year-old male presents for evaluation of a suspicious lesion on the mid-forehead area.

Clinical evaluation reveals changes suspicious for basal cell carcinoma. A skin biopsy is considered necessary and appropriate to clarify the diagnosis. The procedure is explained to the patient, including the potential for bleeding, infection, and scarring. All of the patient’s questions are answered and the patient provided his informed verbal consent.

The area is injected with 1% lidocaine with epinephrine local anesthetic and a tangential (shave) biopsy of the mid-forehead is performed using a #15 scalpel blade to remove the superficial portion of the lesion. Aluminum chloride 35% is used for hemostasis. A dressing with triple antibiotic ointment is applied. The patient tolerated the procedure well. Written wound-care instructions are provided. The patient is advised that he will be notified of the pathology results and will be asked to return to the office for follow-up, according to the results.

Examination also revealed an actinic keratosis (x1) on the left forearm. The etiology is discussed, and the patient is made aware of the pre-cancerous nature of the lesion. Treatment with liquid nitrogen cryotherapy is recommended. The procedure, risks, and benefits are explained to the patient, including the potential for bleeding, infection, hypopigmentation, and scarring. All of the patient’s questions are answered and patient provided his verbal consent.

The lesion is treated with liquid nitrogen at the time of the visit. The patient tolerated the procedure well. The expected crusting and/or blistering response is discussed with patient. The proper care of the treatment area at home is discussed and information is printed and given to the patient.

Example 2

A 79-year-old male presents for his annual skin examination. Examination of the right sideburn and right temple areas reveals two pearly papules. Biopsy of the two lesions is recommended. The procedure is explained, including the potential for bleeding, infection, and scarring. All of the patient’s questions are answered. Informed verbal consent is obtained from the patient. A biopsy is performed at the time of the visit by tangential technique using a scalpel blade. Aluminum chloride 35% is used for hemostasis. A dressing with bacitracin is applied. The patient tolerated the procedure well. Written wound-care instructions are provided to the patient and he is informed that he will receive a phone call in about a week regarding the biopsy results.

Examination of the mid-frontal scalp also reveals a keratotic lesion with an erythematous base. Biopsy of the lesion is recommended. The procedure is explained, including the potential for bleeding, infection, and scarring. The patient’s questions are answered. Informed verbal consent is obtained from the patient. A biopsy is performed at the time of the visit using the tangential technique with a scalpel blade. Aluminum chloride 35% is used for hemostasis. A dressing with bacitracin is applied. The patient tolerated the procedure well. Written wound-care instructions are provided to the patient and he is informed that he will receive a call in about a week regarding the biopsy results.

Example 3

A 64-year-old male with a history of renal transplant and chronic lymphocytic leukemia presents for evaluation of multiple problems that have developed. His renal function has been worsening and he has needed intermittent hemodialysis. He is on multiple medications, including immunosuppressive agents. He has developed a widespread purpuric eruption within the last two days after being prescribed an antibiotic for an ulcerative plaque on his thigh by his primary care physician. The ulcer is painful and enlarging. He also has a purpuric nodule on the right ankle and three keratotic nodules on the right forearm. He feels ill and will be seeing his nephrologist later in the afternoon.

Examination reveals a 10 x 14 cm purpuric plaque on the left thigh with central ulceration. He has multiple erythematous and non-blanching macules and papules on the chest, back, and extremities. A 14 x 8 mm plum-colored nodule is noted on the right ankle. The right forearm reveals an 18 x 12 mm crateriform lesion on the right extensor surface of the forearm, about 7 cm from the elbow. A 7 x 8 mm keratotic papule is noted on the right forearm near the right wrist, and an 11 x 11 mm lesion is noted between the two other right forearm lesions.

Impression:

1. Drug eruption vs vasculitis: A punch biopsy is recommended to help clarify the diagnosis. The risks and benefits are discussed and reviewed. The patient agrees. A 4-mm punch biopsy is performed on a representative early lesion on the right lower leg after the area is prepared and draped and anesthetized with 1% lidocaine. Two 4-0 monofilament polybutester sutures are used to close the defect.

2. Pyoderma gangrenosum vs infection vs calciphylaxis: An incisional biopsy is recommended to clarify the diagnosis. The patient is agreeable to the procedure. The area is prepared and draped in the usual fashion. A 1% lidocaine is used for anesthesia and a 2-cm long elliptical incisional biopsy is obtained to include the central ulcer and purpuric border. The specimen included fat that showed evidence of necrosis. A gritty sensation is noted when excising the tissue, furthering the suspicion of underlying calciphylaxis and is noted on the pathology requisition.

3. Possible Kaposi’s sarcoma on the right ankle vs hemosideratotic dermatofibroma or acroangioder-matitis: A tangential biopsy is recommended and performed to obtain tissue sample for histopathologic examination using a #15 blade.

4. Keratotic papules on the right forearm: These lesions are suspicious for squamous cell carcinoma arising in the setting of immunosuppression.

   Sporothricosis is in the differential diagnosis but appears less likely as the lesions are not clearly situated along lymphatic channels. Tangential biopsy of all three lesions is recommended and performed using shave technique with a scalpel blade.

Example 4

A 49-year-old female presents for evaluation of two new suspicious lesions located on the upper and lower left lateral neck. Biopsy of the two lesions is recommended to confirm diagnosis. The procedure is explained and the potential for bleeding, infection, and scarring is discussed with the patient. All of the patient’s questions are answered. Patient provided her informed verbal consent.

Both suspicious lesions are anesthetized with 1% lidocane with 1:100,000 epinephrine after sterile preparation and drape. Tissue samples are obtained via shave technique using a #15 blade. Hemostasis is achieved by light electrodesiccation. The tissue is transported to the laboratory for sectioning and histopathologic study.